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Cardiac CT

Landmark Articles

The relationship between resting heart rate and incidence and progression of coronary artery calcification: The multi-ethnic study of atherosclerosis (MESA).
By: Rubin J, Blaha MJ, Budoff MJ, Rivera JJ, Shaw LJ, Blankstein R, Mallah MA, Carr JJ, Jones DL, Blumenthal RS, Nasir K.
Elevated resting heart rate has been independently associated with cardiovascular and all-cause mortality. The pathophysiological mechanisms by which this increased risk occurs are unclear. We hypothesized that elevated resting heart rate would be associated with increased development of atherosclerosis, as assessed by the incidence and progression of CAC. We concluded that elevated resting heart rate, a well-described predictor of cardiovascular mortality with unclear mechanism, is associated with increased incidence and progression of coronary atherosclerosis among individuals free of CVD at baseline.
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Association between obesity, high-sensitivity C-reactive protein greater than or equal to 2 mg/L, and subclinical atherosclerosis: implications of JUPITER from the Multi-Ethnic Study of Atherosclerosis.
By: Blaha MJ, Rivera JJ, Budoff MJ, Blankstein R, Agatston A, O’Leary DH, Cushman M, Lakoski S, Criqui MH, Szklo M, Blumenthal RS, Nasir K.

Levels of hsCRP are closely associated with abdominal obesity, metabolic syndrome, and atherosclerotic cardiovascular disease. The JUPITER trial has encouraged using hsCRP greater than or equal to 2 mg/L to guide statin therapy; however, the association of hsCRP and atherosclerosis, independent of obesity, remains unknown. We concluded that high hsCRP, as defined by JUPITER, was not associated with CAC and was mildly associated with carotid intima-media thickness (cIMT) in the absence of obesity. In contrast, obesity was associated with both measures of subclinical atherosclerosis independently of hsCRP status.

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Relation of mitral annular calcium and coronary calcium (from the Multi-Ethnic Study of Atherosclerosis [MESA]).
By: Hamirani YS, Nasir K, Blumenthal RS, Takasu J, Shavelle D, Kronmal R, Budoff M.
Atherosclerosis is a complex diffuse disorder. The close correlation between CAC score on computed tomography and extent and severity of coronary atherosclerosis is well established. It has been suggested that mitral annular calcification (MAC) may be a manifestation of generalized atherosclerosis. We observed a strong association between MAC and increasing burden of CAC. This association weakened but persisted after adjustment for age, gender, and other traditional risk factors. These findings suggest that presence of MAC is an indicator of atherosclerotic burden rather than just a degenerative change of the mitral valve.
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Association between high-sensitivity C-reactive protein and coronary plaque subtypes assessed by 64-slice coronary computed tomography angiography in an asymptomatic population.
By: Rubin J, Chang HJ, Nasir K, Blumenthal RS, Blaha MJ, Choi EK, Chang SA, Yoon YE, Chun EJ, Choi SI, Agatston AS, Rivera JJ.
We evaluated 1,004 asymptomatic South Korean subjects (mean age, 49±9 years) who underwent coronary computed tomography angiography (CCTA) as part of a health screening evaluation. We examined the association between increasing CRP levels and plaque subtypes using multivariable linear and logistic regression analysis. We concluded that elevated levels of CRP are associated with an increased prevalence of mixed coronary atherosclerotic plaque (MCAP) as assessed by CCTA. Longitudinal studies will determine if the excess risk observed in persons with elevated CRP may be mediated, at least in part, by an increased burden of MCAP.
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“Actually, it is more of a guideline than a rule.”
By: Blumenthal RS, Hasan RK.
This editorial discusses the challenges of designing a randomized controlled trial of coronary calcium scanning to improve risk prediction. It also emphasizes the theme of the iconic movie “Ghostbusters.”
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Society for Atherosclerosis Imaging and Prevention Tomographic Imaging and Prevention Councils. Guideline for minimizing radiation exposure during acquisition of coronary artery calcium scans with the use of multidetector computed tomography.
By: Voros S, Rivera JJ, Berman DS, Blankstein R, Budoff MJ, Desai MY, Hecht HS, Nasir K, Santos RD, Taylor AJ, Weissman G.

Coronary artery calcium (CAC) scanning is an important tool for risk stratification in intermediate-risk, asymptomatic subjects without previous coronary disease. However, the clinical benefit of improved risk prediction needs to be balanced against the risk of the use of ionizing radiation. Although there is increasing emphasis on the need to obtain CAC scans at low-radiation exposure to the patient, very few practical documents exist to aid laboratories and health care professionals on how to obtain such low-radiation scans. The Tomographic Imaging Council of the Society for Atherosclerosis Imaging and Prevention, in collaboration with the Prevention Council and the Society of Cardiovascular Computed Tomography, created a task force and writing group to generate a practical document to address parameters that can be influenced by careful attention to image acquisition. Patient selection for CAC scanning should be based on national guidelines. It is recommended that laboratories performing CAC examinations monitor radiation exposure (dose-length-product [DLP]) and effective radiation dose (E) in all patients. DLP should be <200 mGy × cm; E should average 1.0-1.5 mSv and should be <3.0 mSv. On most scanner platforms, CAC imaging should be performed in an axial mode with prospective electrocardiographic triggering, using tube voltage of 120 kVp. Tube current should be carefully selected on the basis of patient size, potentially using chest lateral width measured on the topogram. Scan length should be limited for the coverage of the heart only. When patients and imaging parameters are selected appropriately, CAC scanning can be performed with low levels of radiation exposure.

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Associations of SNPs in ADIPOQ and subclinical cardiovascular disease in the multi-ethnic study of atherosclerosis (MESA).
By: Wassel CL, Pankow JS, Rasmussen-Torvik LJ, Li N, Taylor KD, Guo X, Goodarzi MO, Palmas WR, Post WS.
Circulating adiponectin is associated with both clinical and subclinical CVD. Variants of the adiponectin gene (ADIPOQ) are associated with clinical CVD, but little is known about associations with subclinical CVD. We studied the association of 11 ADIPOQ SNPs with common and internal cIMT, presence of CAC, and CAC scores (in those with CAC) in 2,847 participants in MESA. There appears to be an association between ADIPOQ SNPs and subclinical CVD in African Americans and Hispanics. Replication as well as assessment of other ADIPOQ SNPs is warranted.
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Thoracic aortic calcification and coronary heart disease events: the multi-ethnic study of atherosclerosis (MESA).
By: Budoff MJ, Nasir K, Katz R, Takasu J, Carr JJ, Wong ND, Allison M, Lima JA, Detrano R, Blumenthal RS, Kronmal R.
The presence and extent of CAC is an independent predictor of CHD morbidity and mortality. Few studies have evaluated interactions or independent incremental risk for coronary and thoracic aortic calcification (TAC). The independent predictive value of TAC for CHD events is not well-established. This study used risk factor and computed tomography scan data from 6,807 participants in MESA. Using the same images for each participant, TAC and CAC were each computed using the Agatston method. Our study indicates that TAC is a significant predictor of future coronary events only in women, independent of CAC. On studies obtained for either cardiac or lung applications, determination of TAC may provide modest supplementary prognostic information in women with no extra cost or radiation.
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Mortality in individuals without known coronary artery disease but with discordance between the Framingham risk score and coronary artery calcium.
By: Ahmadi N, Hajsadeghi F, Blumenthal RS, Budoff MJ, Stone GW, Ebrahimi R.
A risk-management approach based on the Framingham risk score (FRS), although useful in preventing future CAD events, is unable to identify a considerable portion of patients with CAD who need aggressive medical management. CAC, an anatomic marker of atherosclerosis, correlates well with presence and extent of CAD. This study investigated mortality risk associated with CAC score and FRS in subjects classified as “low risk” versus “high risk” based on FRS. In conclusion, the prognostic value of CAC to predict future mortality is far superior to the FRS. Addition of CAC score to FRS significantly improves the identification and prognostication of patients without known CAD.
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Factors associated with presence and extent of coronary calcium in those predicted to be at low risk according to Framingham risk score (from the Multi-Ethnic Study of Atherosclerosis).
By: Okwuosa TM, Greenland P, Lakoski SG, Ning H, Kang J, Blumenthal RS, Szklo M, Crouse JR 3rd, Lima JA, Liu K, Lloyd-Jones DM.
Even among asymptomatic persons at low risk (<10% risk of an MI over the next decade) according to the Framingham risk score, high CAC scores signify a greater predicted risk of CHD events. We determined the noninvasive factors (without radiation exposure) significantly associated with CAC in low-risk, asymptomatic persons. In a cross-sectional analysis, we studied 3,046 individuals at a low 10-year predicted risk (Framingham risk score <10%) of CHD events. In low-risk persons, the traditional risk factors alone predicted advanced CAC with high discrimination and calibration. The biomarker combinations with and without cIMT were also significantly associated with advanced CAC; however, the improvement in the prediction and estimation of the clinical risk were modest compared to the traditional risk factors alone.
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